Journal of Experimental Orthopaedics

Purpose Patients undergoing total knee arthroplasty (TKA) are at a high risk of thromboembolic events, which is higher in obese patients. Determining the appropriate prophylaxis for venous thromboembolism (VTE) in obese patients is challenging. Therefore, we aimed to compare the effects of low molecular weight heparin (LMWH) with aspirin (ASA) and their combination for the prevention of thromboembolic events after TKA in obese patients. Methods In a retrospective study, 245 obese patients with BMIs over 30 who underwent TKA were enroled. Eligible patients were divided into three groups: Group A was given LMWH sodium (Clexane®) for 14 days, Group B was given ASA for 14 days, and Group C was given LMWH sodium (Clexane®) for 5 days and then ASA twice daily for the days between 5 and 14 postoperatively. The primary outcome was the incidence of VTE within three months. Secondary outcomes included routine laboratory evaluations (PT, PTT, INR, Hb, Hct, platelets, BUN and Cr) and adverse effects of ASA and LMWH, such as bleeding, anaemia, thrombocytopenia, and gastrointestinal or neurological symptoms. Results Regarding the incidence of DVT and PTE, we did not observe significant differences between groups (p > 0.05). A total of seven symptomatic VTE was observed in six patients. We observed two cases with PE who were in the Clexane group. Moreover, five individuals had DVT in the follow‐up: three cases in the Clexane group, one in the ASA group, and one in the ASA + Clexane group, which was not statistically significant (p > 0.05). There were no differences between groups regarding the risk of adverse events and complications. Conclusion We found that ASA is not inferior to enoxaparin in reducing VTE after TKA in obese patients. Therefore, given ASA's low cost and greater convenience, it may be considered a reasonable alternative for extended VTE prophylaxis for TKA surgery in obese patients. Level of Evidence Level III.

Purpose This study sought to validate intraoperative robotic measurements of femoral and tibial component coronal alignment in total knee arthroplasty (TKA) by comparing to pre‐ and post‐operative standing, double stance, long‐leg radiographs (LLR). Methods This retrospective cohort study included 59 unique patients undergoing primary TKA at a single institution. Pre‐ and post‐operative femoral and tibial coronal alignment were measured on LLRs using a deep learning artificial intelligence model and compared to measurements obtained from the imageless robotic system to evaluate the robot's accuracy and reliability. Results Robotic measurements were highly correlated with measurements from preoperative LLR (Pearson r² = 0.68). There was no significant difference in preoperative constitutional alignment between the two methodologies (p = 0.28). Additionally, the intraoperative and post‐operative alignment of femoral and tibial implants were not significantly different (p = 0.12 and p = 0.95, respectively) and were strongly correlated (Pearson r² = 0.5 and Pearson r² = 0.6 respectively). The mean difference in femoral alignment was 0.43° and the mean difference in tibial alignment was 0.01°. Conclusions The findings of this study suggest that there were no significant differences in the coronal alignment of TKA when assessed by a robotic system compared to LLR. This signifies the robotic system's high intraoperative accuracy and reliability in determining coronal alignment. Level of Evidence Level III.

Purpose The aim of this study is to investigate the influence of patient‐specific factors, including age, lifestyle considerations as well as the extent of injury according to the Rockwood classification (RW), on the surgeon's decision‐making in the choice between operative and nonoperative treatment for acute, high‐grade acromioclavicular (AC) joint dislocations. Methods Orthopaedic and trauma surgeons were requested to complete an online questionnaire consisting of closed and open questions regarding the treatment of acute, high‐grade AC joint dislocations and 24 fictive clinical scenarios. Results A total of 133 answered questionnaires were collected. 27 different nationalities from five continents were represented. The included participants had a median experience of 12 years (interquartile range: 2–41). Overall, the treatment option for surgery (answer: YES) was chosen in 2426 answers (76% of cases) compared to ‘NO’ in 766 (24% of cases). RW classification was considered the most important factor influencing surgical decision‐making for most surgeons (69%). Two thirds of the participants answered that smoking does not impact their decision towards surgery and as to the influence of body mass index (BMI) on decision‐making, half of the respondents would not alter their preferred treatment based on BMI. Finally, there were no significant differences in decision‐making regarding the influence of the participant's demographics. Conclusion This study highlights that RW classification is the most important factor to consider in the surgeon's decision‐making between operative and nonoperative treatment in acute, high‐grade AC joint dislocations. Participants preferred operative treatment over nonoperative treatment in acute, high‐grade AC joint dislocation in 76% of case scenarios, increasing up to 90% when RW Grade III lesions were not taken into account. These findings contrast with recent studies reporting good functional outcomes of conservatively treated acute, high‐grade AC injuries and highlight the need to bridge the gap between evidence and practice. Level of Evidence Level V.

Purpose To compare postoperative activity levels between patients who received an anterior cruciate ligament reconstruction (ACLR) with‐ and without a lateral extra‐articular procedure (LEAP). Objectives The primary objective is to examine whether patients treated with an ALCR and LEAP have a greater chance to return to sport (RTS) and return to their pre‐injury level of sport (RTPS). The re‐rupture rates between the two groups will also be analysed as this is of great influence on the RTS and RTPS. Methods A thorough search according to PRISMA guidelines was conducted through the PubMed and Embase databases in May 2024. Randomised controlled trials (RCT) and retrospective cohort studies on patients who underwent primary ACLR with‐ or without a LEAP were included. Postoperative Tegner score, RTS, RTPS and re‐rupture rate were evaluated. All articles were revised according to Cochrane risk of bias tools (RoB 2.0 and ROBINS‐I). Results Twenty‐four studies were included after examining 966 titles, abstracts and manuscripts. A total of 33,527 patients were included in this review with a weighted mean age of 24.9 years. Pooled data demonstrates that the ACLR + LEAP group shows significantly higher postoperative Tegner scores (MD, 0.43 [95% confidence interval, 0.21–0.65]; p < 0.01). 62% of patients who underwent ACLR + LEA returned to their pre‐injury level of sport compared to 40% in ACLR group (reported in nine studies). Conclusion This meta‐analysis demonstrates that patients undergoing a LEAP procedure in addition to ACLR return to higher postoperative activity levels and are more likely to return to their pre‐injury level of sport. These results ‐in addition to further research‐ may help dictate when to add a LEAP, and whether LEAP in addition to ACLR should become the golden standard. Level of Evidence Level III, retrospective cohort studies have been analysed, alongside RCT's, and thus this is the level of evidence.

Purpose Individuals with excessive knee rotation have higher levels of dysfunction and disability. An inexpensive, and reliable method to assess knee internal (IR) and external (ER) rotation will improve the assessment of knee injuries. The study explored the reliability and measurement error of two methods of knee rotation measurement. The study tested the hypothesis that the digital inclinometer will provide reliable measures of knee internal and external rotation and that the digital inclinometer measurements will be consistent with the measurements made with the electromagnetic tracking system. Methods Twenty (20) participants without knee injury participated. Knee IR and ER were measured using electromagnetic tracking and a digital inclinometer. The intraclass correlation coefficient (ICC(2,1)) was calculated for both techniques. Results The within device ICC values ranged from 0.826 to 0.939 for both devices. The within‐device minimal detectable change (MDC) ranged from 1.2° to 1.9°. The ICC values for EI and IR measures collapsed between the devices, ranged from 0.717 to 0.859. The MDC calculated between devices ranged from 1.6° to 1.9°. Conclusion The results of the current study show that knee IR and ER can be measured reliably with both measurement techniques. The measurement of knee ER and IR did not differ between the two devices or between the right and left sides. Level of Evidence Level IV, diagnostic, case series study.

Treatment options for acute acromioclavicular joint (ACJ) instability include several surgical and non‐surgical approaches. Recent trends indicate a shift towards nonoperative treatment, even for severe Rockwood type V injuries, which traditionally required surgery. Despite this shift, some patients may still benefit from surgical stabilisation, particularly if significant pain and disability persist. Modern surgical techniques focus on cortical button systems and restoration of the coracoclavicular ligaments, emphasising the importance of the posterosuperior acromioclavicular capsuloligamentous complex in managing horizontal instability. Clavicular hook plates offer rigid stability but present risks, such as damage to the subacromial structures and acromial erosion. Although anatomical repair techniques have gained prominence due to their biomechanical advantages and have been endorsed by international societies, non‐anatomic methods may also provide acceptable outcomes with lower costs. The use of tendon grafts in chronic ACJ instability has shown promise, although evidence for their use in acute cases remains limited. This review discusses various treatment strategies, including operative and nonoperative management, focusing on patient outcomes, complication rates, and return‐to‐sport scenarios. Ultimately, the choice between surgical and non‐surgical treatment must consider individual patient needs and the potential for long‐term recovery. Level of Evidence: Not applicable.

Purpose This study aimed to evaluate the demographic features of patients undergoing wrist arthroscopy in Italy. A secondary aim was to perform an economic analysis of this type of surgery. Methods The National Hospital Discharge Records database was employed to conduct the analysis. Wrist arthroscopy surgical procedures were defined by the primary procedure code 80.23, according to the International Classification of Diseases, Ninth Revision–Clinical Modification code. Incidence rates were computed by dividing the number of annual cases by the size of the adult population reported annually by the National Institute for Statistics. Results 7875 wrist arthroscopy procedures were performed in Italy. The cumulative incidence rate was 1 for every 100,000 Italian residents. The need for wrist arthroscopy in Italy increased from 2001 to 2008 and then progressively declined up to 2016. The highest number of procedures was found between 40 and 49 years. Most patients undergoing wrist arthroscopy were females (50.6%). The mean age of patients was 41.6 ± 14.5. Wrist arthroscopy in Italy costs an average of 721,102 ± 171,195€ each year. Conclusions The incidence of this type of surgery peaked throughout the course of the 15 years, in 2006 and 2008. However, the number of procedures per 100,000 inhabitants has decreased since 2008. The economic analysis revealed that the cost of wrist arthroscopy is relevant to the healthcare system in Italy. Level of Evidence Level II.

Purpose Swelling after total knee replacement surgery can hinder recovery, cryotherapy is one of the non‐pharmacological interventions. However, the evidence of effectiveness is limited, possibly due to the heterogeneity of parameters. This scoping review aims to summarise existing evidence, clarify the mechanism and effect of cryotherapy on swelling after total knee arthroplasty, and analyze various parameters, providing evidence for clinical practice and future research. Methods A literature search was performed on PubMed to include articles which reported on the cryotherapy impacts postoperative swelling after total knee arthroplasty. Snowballing research was used to obtain more sources. Results A total of 69 studies were identified from the initial research, of which 40 articles were included for the full text analysis. Cryotherapy primarily acts on swelling by reducing haemorrhage and inflammatory responses. The level of evidence for the effectiveness of cryotherapy is low, and there is no standard in its parameters. The initiation of cryotherapy is increasingly recommended to start immediately after surgery. The selection of treatment temperature needs to balance efficacy and safety, but measuring intra‐articular temperature presents obstacles, making skin temperature a more feasible option. However, it is unclear how to achieve the desired skin temperature by setting a combination of treatment temperature, pressure and duration. When determining the length of the interval, particular attention should be paid to the changes in blood perfusion levels during the rewarming phase, as evidence suggests that skin temperature during rewarming may not accurately reflect the actual level of blood perfusion. The location and duration of cryotherapy can be preliminarily determined through existing evidence and mechanism analysis. Conclusion Some cryotherapy parameters are supported by evidence and can be practiced in clinical practice. It should be noted that skin temperature has limitations as an observation indicator during the rewarming stage, and the frequency of cold therapy needs further research to determine. Level of Evidence Level IV.

Purpose Triple‐Osteotomy (TO) is a hip‐preserving surgical technique designed to correct symptomatic hip dysplasia by achieving three‐dimensional acetabular reorientation and improving femoral head coverage. This procedure has shown promising outcomes in pain reduction, functional recovery, and quality of life, particularly in young, active patients. While periacetabular‐osteotomy (PAO) is another well‐established method for hip preservation, the specific advantages of TO, especially in early recovery and patient‐reported outcomes (PROMs), remain underexplored. This study evaluates the mid‐term outcomes of TO using the iHOT33 tool to provide a comprehensive understanding of its clinical benefits. Methods This non‐randomised, retrospective registry study within the German Cartilage Registry included 48 patients with symptomatic, radiologically confirmed hip dysplasia who underwent TO by the same specialist. The follow‐up rate at 24 months was 60.4% with a mean follow‐up time of 24 months. Outcomes measured included iHOT33 scores, quality of life, VAS for pain, satisfaction, perceived treatment benefit, and unemployment rate. Paired t‐tests and regression analysis (p < 0.05) were applied. Results Preoperative iHOT33 scores averaged 46.9, increasing to 70.8 after 24 months (Δ 23.9), with notable improvement in the first 6 months (Δ 15.8). The “social” subdomain showed the greatest improvements (Δ 30 points), alongside improvements in quality of life and pain reduction (VAS). Postoperative angles (VCE 31° ± 4°, acetabular index 0° ± 3°) were within the normal range. No significant correlation was found between angle changes and iHOT33 scores, indicating benefits across dysplasia severities. Conclusions Triple‐osteotomy offers significant and rapid improvements in patient‐reported outcomes for individuals with hip dysplasia, particularly in enhancing social and sports‐related quality of life as measured by iHOT33 and other subjective assessments. Its potential advantages over Periacetabular‐osteotomy, especially in terms of early recovery, warrant further investigation through prospective, comparative studies to better define its role in hip‐preserving surgical strategies. Level of Evidence Level III.

This study aims to investigate the association between chronic lateral meniscus posterior root tears (LMPRTs) and chondral or osteochondral lesions of the lateral femoral condyle (LFC), particularly in cases involving prior anterior cruciate ligament (ACL) injuries. Given the challenges in diagnosing LMPRTs and the biomechanical significance of the lateral meniscus, this research highlights the potential long‐term impact of untreated root tears. A prospective analysis was conducted on seven patients with chronic LMPRTs and suspected LFC lesions, identified through clinical symptoms, history of ACL injuries and magnetic resonance imaging (MRI) findings. The presence of LMPRTs was confirmed via arthroscopy, and the lesions were classified using the LaPrade Classification. The patients underwent various surgical interventions, including ACL reconstruction with lateral tenodesis and meniscus repair. All seven cases demonstrated a significant association between chronic LMPRTs and chondral/osteochondral lesions of the LFC. The lesions were consistently located in the posterolateral compartment, with MRI indicating subchondral bone oedema and cartilage thinning. Surgical findings confirmed Type II posterior root tears in all patients, with subsequent repair. The study suggests that chronic LMPRTs, especially in the context of ACL injuries, may contribute to the development of chondral or osteochondral lesions in the LFC. This association underscores the importance of early diagnosis and treatment of meniscus root tears to prevent long‐term joint degeneration. Increased awareness and improved diagnostic techniques are essential for better clinical outcomes. Level of Evidence: Level IV, case series.

Purpose The aim of this study was to determine the influence of preoperative psychological factors on clinical outcomes of fresh osteochondral allograft (FOCA) transplantation of the knee. The hypothesis was that patients with preoperative pathological scores on psychological factors would show worsen functional outcomes after FOCA transplantation of the knee. Methods A prospective data collection study was performed from patients undergoing FOCA transplantation for osteochondral lesions of the knee. All patients were followed up for 30 months. Psychological factors of anxiety, depression, kinesiophobia and catastrophizing were assessed by means of self‐administered Hospital Anxiety and Depression Subscale (HADS), Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) questionnaires one week prior to surgery. Clinical outcomes were evaluated preoperatively and at 3, 6, 9, 12, 15 and 30 months postoperatively using the Kujala score, the Western Ontario Meniscal Evaluation Tool (WOMET) score, the International Knee Documentation Committee (IKDC) score and the Tegner Activity Scale. Participants were classified as pathological or non‐pathological scores for each psychological parameter in accordance with the cut‐off point proposed by the authors of each questionnaire. The interaction between clinical outcome's evolution and pathological scores was analysed using two‐way ANOVA tests with Greenhouse–Geisser correction to avoid non‐sphericity errors. Results Forty‐one cases were included (mean age 37.1 years old, 41% female). In the postoperative clinical outcome's evolution, no differences were observed between preoperative pathological and non‐pathological scores (p > 0.05) regarding anxiety, depression, kinesiophobia and catastrophizing factors. Conclusions No significant differences were observed in the evolution of postoperative clinical outcomes between patients with pathological and non‐pathological psychological scores. Level of Evidence Level III, case series.

Purpose Weight‐bearing computed tomography (WBCT) creates colour‐coded distance maps (DM) to analyze intraarticular contact areas, offering a detailed assessment of joint surface interactions. However, clinical applications of DM remain underexplored. This study introduces the ‘Battleship technique (BST)’ to evaluate contact area patterns in patients with osteoarthritis (OA) of the talar dome, producing a single point representing the distance map weighted sum (DMWS). The DMWS serves as a potential reference for assessing hindfoot deformities and guiding clinical decisions, including surgical planning and alignment correction. We hypothesize that the BST is reliable for calculating the DMWS and that the DMWS correlates with hindfoot alignment, providing a novel tool to improve the evaluation of complex deformities. The primary aim was to evaluate the reliability of the BST, and the secondary aim was to determine whether the DMWS is influenced by hindfoot alignment. Methods Two raters independently calculated DMWS using BST for forty ankle OA patients. Based on DMWS location relative to the joint centre, patients were categorized into coronal (varus/valgus) and sagittal (anterior/posterior) groups. Hindfoot alignment was statistically compared between groups. Results Excellent interobserver and intraobserver agreement was observed. Significant differences were found in α angle, tibiotalar surface angle (TSA), hindfoot alignment angle (HFA) and talar tilt (TT) (p = 0.047, p < 0.001, p = 0.003 and p = 0.04) between coronal groups, and in β angle and tibiotalar ratio (TTR) (p < 0.001) between sagittal groups. Correlations were identified between DMWS and TSA (r = 0.6, p < 0.001), TT (r = −0.6, p < 0.001), β angle (r = 0.2, p < 0.001) and TTR (r = −0.4, p < 0.001). Conclusion The BST reliably calculates the DMWS, correlating with foot and ankle alignment. BST provides a standardized, non‐invasive method to evaluate intraarticular contact patterns, offering valuable insights for preoperative planning and post‐operative assessment. Its integration into practice may enhance surgical precision in complex realignment procedures. Level of Evidence Level IV.

Purpose To compare displaced bucket‐handle meniscus repair (BHMR) failure rates, subjective and objective knee function after BHMR in the setting of ACLR performed as a single‐or two‐stage procedure, and assess factors associated with BHMR survival. Methods This retrospective study included patients who underwent surgery between February 2015 and December 2021 at one institution. Patients with a displaced bucket‐handle meniscus tear (BHMT) and ACL‐injury undergoing BHMR and ACLR as a single‐ (concomitant BHMR and ACLR) or two‐stage (BHMR and subsequent ACLR) procedure were identified. The primary outcome was the 2‐year BHMR failure rate following ACLR, defined as reoperation with meniscus re‐repair or resection. Additionally, 6‐month range of motion (ROM), isokinetic knee (extension, flexion) strength, 1‐and 2‐year Knee injury and Osteoarthritis Outcome Score (KOOS), Patient‐acceptable symptom state (PASS), treatment failure (TF) were compared between the groups. Kaplan‐Meier analysis was performed to assess BHMR survival, factors associated with repair survival were analysed through Cox proportional hazard regression analysis. Results The cohort included 159 displaced BHMRs, 120 (75.5%) underwent single‐stage surgery. The overall BHMR failure rate was 27% (43/159). The single‐stage surgery group had significantly lower failure rate (15% vs. 35.9%, p = 0.006). BHMT laterality, subjective (KOOS, PASS and TF) and objective (ROM, isokinetic strength) knee function did not differ significantly between the groups. Conclusion Patients who underwent single‐stage displaced BHMR and ACLR had significantly lower BHMR failure rate compared to those who underwent two‐stage surgery. Therefore, single‐stage displaced BHMR and ACLR should be advocated, although patient‐specific factors and further prospective studies remain important considerations. Level of Evidence Level III.

Purpose Clinical evidence indicates that an unintended increase in the medial proximal tibial angle (MPTA) can occur during slope‐reducing tibial osteotomies, which is most relevant in anterior cruciate ligament (ACL) deficient knees. Therefore, the purpose of this three‐dimensional (3D) simulation study is to assess how axial or coronal hinge axis rotation affect alignment parameters in anterior tibial closing wedge osteotomies (ACWO). The hypothesis states that a neutral hinge axis (NHA) in ACWO prevents changes in coronal and axial alignment. Methods A 3D surgical simulation was used to perform ACWO with a stepwise increment of one‐degree (1°–5°) rotation around thirteen different hinge axes. Surface models were created from CT scans of 49 individuals (mean PTS 11.5° ± 3.8°) resulting in 3185 simulations. A NHA not changing the coronal or axial alignment was defined as oriented parallel to the posterior tibial plateau 1 cm underneath the articular surface. Anatomical landmarks were determined for each simulation to measure the PTS, MPTA, hip‐knee‐ankle angle (HKA), and tibial torsion (TT). The effects of the initial MPTA or PTS on the resulting alignment parameters and the effects of axial and sagittal rotation of the joint axis were analysed for their effects on postsimulation PTS, MPTA and TT. Results Clinically relevant hinge axis rotation in the coronal or axial plane below 20° did not significantly influence PTS correction (p > 0.05). Axial rotation of the hinge axis exceeding 10° led to significant MPTA changes (> +1.7° ± 0.03°) compared to the NHA (p < 0.001). Pre‐simulation MPTA had no influence on post‐simulation MPTA changes (p > 0.05). Conclusion NHA aligned parallel to the posterior tibial plateau below the articular surface prevents significant changes in MPTA during ATCWO. This 3D simulation suggest, that hinge axis orientation requires meticulous consideration during slope‐reducing osteotomies to preserve alignment integrity. Level of Evidence Level V, retrospective simulation study.

Purpose The aim of this study is to evaluate the impact of graft size and time between injury to surgery (TBIS) on static anterior tibial translation (SATT) and dynamic anterior tibial translation (DATT) after anterior cruciate ligament (ACL) reconstruction. Methods A consecutive series of patients treated with primary ACL reconstruction using hamstring autograft was reviewed. Preoperative SATT, DATT and posterior tibial slope (PTS) were measured with a previously validated technique by two independent reviewers on lateral weight‐bearing knee radiographs. Regression analysis was performed to assess the relationship between postoperative—preoperative SATT difference (Δ SATT) and postoperative—preoperative DATT difference (Δ DATT) with graft size and TBIS. Results In total, 66 patients were included in this study. The mean preoperative SATT and DATT were 2.41 (standard deviation [SD] 2.98) and 9.09 (SD 3.19), respectively. The mean postoperative SATT and DATT were 2.14 (SD 2.47) and 5.28 (SD 2.55), respectively. The mean graft size was 8.4 mm (SD 8.4; range 7.75–10), and the median TBIS was 3 months (range 1–275). Linear regression analysis showed no correlation between graft size and Δ SATT (p = 0.060) and Δ DATT (p = 0.979) and no correlation between TBIS and Δ SATT (p = 0.817) and Δ DATT (p = 0.811). Conclusion Our results suggest that larger graft sizes or shorter times between injury and reconstruction do not impact the reduction of SATT or DATT following ACL reconstruction. Level of Evidence Level IV, retrospective cohort study.

Purpose The purpose of this study was to evaluate patient outcomes following anterior cruciate ligament reconstruction (ACLR) complicated by septic arthritis treated with graft retention versus graft removal protocols. Secondarily, this study aimed to evaluate surgical, demographic and microbial surgical indications for graft retention versus graft removal. We hypothesised that patients who underwent graft removal would have worse outcomes and that patients with septic arthritis caused by more virulent organisms, such as methicillin‐resistant Staphylococcus aureus or Pseudomonas aeruginosa, would be more likely to undergo graft removal. Methods A systematic review and meta‐analysis of literature in the PubMed and Ovid databases regarding the treatment of septic arthritis following ACLR reporting graft retention versus graft removal was conducted. The included studies were published in English, in peer‐reviewed journals, with an average minimum follow‐up of 1 year, and reported on arthroscopic ACLR, surgical management of infection, graft retention versus graft removal during treatment and outcome measures. Patient demographic, surgical and outcome data were analysed. Results Twenty‐four studies reporting on 307 patients were included for analysis. Patients who underwent allograft ACLR (p = 0.02) and patients with septic arthritis caused by P. aeruginosa (p = 0.03) were more likely to undergo graft removal. Patients treated with graft removal were treated with more irrigation and debridement procedures (2.7 ± 0.8 vs. 2. ± 1.5, p < 0.01). Patients treated with graft removal had increased laxity on KT‐1000 measurement (3.30 ± 134 vs. 1.55 ± 1.23, p < 0.01), and lower 2000 International Knee Documentation Committee Subjective Knee Evaluation scores (66.57 ± 17.08 vs. 80.18 ± 15.21, p = 0.02). Conclusions Septic arthritis following ACLR is a devastating complication. Both graft retention and graft removal protocols have been reported and are viable options. Patients treated with graft removal had poorer outcome measures. Septic arthritis caused by P. aeruginosa and allograft ACLR were more likely to be treated with graft removal. Clinical Relevance Septic arthritis following ACLR remains an uncommon, but difficult problem. There is minimal literature guiding graft retention versus graft removal treatment protocols. Level of Evidence Level IV systematic review of lower‐level studies.

Purpose This study aims to describe a novel minimally invasive technique for the treatment of acute tibial posterior cruciate ligament (PCL) avulsion fracture. Methods This retrospective study included seven patients who underwent ultrasound‐guided fixation for acute PCL tibial avulsion fractures by using an adjustable‐loop device between January 2021 and January 2023. Before the surgery, the maximum diameter, area and displacement distance of the fragments were measured using computed tomography examination. All patients were followed up for at least 12 months, and clinical outcomes were assessed on the basis of range of motion, the International Knee Documentation Committee Score and the Lysholm score. Results For the seven patients, the mean maximum diameter, area and displacement distance of preoperative avulsion fragments were 12.7 mm (range, 9.0–48.3), 128 mm² (range, 63–256.2) and 5.9 mm (range, 3.8–7.2), respectively. These fractures were fixed using an adjustable‐loop suspensory device under ultrasound guidance. Based on x‐ray examination during the post‐operative follow‐up period, all patients had no fracture displacement and fracture unions were confirmed, with a mean union time of 10.28 ± 2.13 weeks (range, 8–14). Based on the knee function assessment at 12‐month post‐operative follow‐up visit, all patients demonstrated excellent clinical outcomes. Conclusions Ultrasound‐assisted internal fixation using an adjustable‐loop device demonstrated satisfactory clinical and radiographic results. This technique has the advantages of being minimally invasive, safe, stable, convenient to operate and thus could be considered as a feasible alternative for the treatment of acute tibial PCL avulsion fractures. Level of Evidence Level III.

Purpose Surgical options for end‐stage knee osteoarthritis (OA) include total and medial unicompartmental knee replacement (TKR and UKR). Deciding which surgery to perform is complex and ill‐defined, yet it has important implications for patients and the health service. The study aimed to identify clinical and surgeon factors predicting surgeons' preferences. Methods Based on a preliminary survey of 162 UK surgeons, we identified clinical features frequently considered when deciding between TKR and UKR. By systematically varying patient age, obesity, site of pain, anaesthetic risk and anterior cruciate ligament (ACL) integrity, we constructed 32 clinical vignettes. We used these in a new survey, where surgeons indicated which surgery they would recommend on an 11‐point rating scale with end points anchored at ‘definitely TKR’ and ‘definitely medial UKR’. Data were analysed with mixed‐effects linear regressions. Results Eighty‐three UK arthroplasty surgeons completed the vignettes. Preference for UKR over TKR was significantly lower for patients over 50 years (b = −0.57 [−0.82 to −0.33], p < 0.001) with abnormal ACL (b = −1.93 [−2.17 to −1.68], p < 0.001) and severe systemic disease (b = −0.46 [−0.70 to −0.21], p < 0.001). Obesity was a weak and unreliable predictor, and we did not detect any influence of site of pain. The surgeons' habitual practice (proportion of UKRs over all knee replacements performed in a typical year) was the second strongest predictor after ACL (b = 1.26 [0.54–1.99], p = 0.001). Conclusions ACL integrity was the most important determinant of surgeons' preferences between TKR and UKR. Their habitual practice was also a strong predictor, outweighing most clinical factors in the vignettes. Level of Evidence Level II, prospective cohort study.

Purpose Previous investigations have associated weakness of neck muscles with a higher likelihood of developing neck pain. However, no previous investigation has examined the influence of neck stabilization exercise (NSE) and dynamic neuromuscular stabilization (DNS) on pain intensity, forward head angle (FHA) and muscle activity. Methods A total of 45 female employees with chronic non‐specific neck pain (CNNP) underwent measurements of pain intensity, FHA and electrical activity of muscles in a slump posture, before and after either NSE or DNS. Results After both stabilization exercise (SE) and DNS the Numeric Pain Rating Scale (NPRS) (F (2,39) = 17.61, p = 0.001, partial η² = 0.475) and forward head posture (FHP), (F (2,39) = 5.509, p = 0.008, partial η² = 0.220), had decreased. Both interventions also decreased the activity in the cervical erector spinae muscle (F (2,39) = 5.31, p = 0.009, partial η² = 0.214), the upper trapezius muscle (F (2,39) = 5.41, p = 0.008, partial η² = 0.217) in slump typing posture, but there was no significant effect on the activity in the sternocleidomastoid muscle (F (2,39) = 2.65, p = 0.083, partial η² = 0.120). Conclusion Both DNS and SE exercises diminished pain intensity, forward head and muscle activity after 6 weeks in patients with CNSNP. Level of Evidence Level I, randomized controlled trials with adequate statistical power.

Purpose The aim of the present study was to compare clinical and radiological outcomes between the all‐inside single bundle (SB) and a modified double‐bundle (DB) anterior cruciate ligament reconstructions (ACLR) at over 5‐year follow‐up. Methods This is an observational, retrospective comparative, two‐centre study. Clinical outcomes were evaluated using Lysholm and International Knee Documentation Committee (IKDC) scores, and anterior tibial translation (ATT) was assessed using the KT‐1000 arthrometer. Knee x‐ray images were recorded, classified according to the KL grading and compared with radiographs of the same patient before surgery. Inclusion criteria were patients undergoing ACLR, age between 18 and 45 years and negative knee history of major traumatic events after surgery. Exclusion criteria were congenital laxity, combined multiple knee ligament injuries, patients undergoing ACL revision surgery, history of infection, lower limb coronal axial deviation >5°, patients undergoing lateral extra‐articular tenodesis or anterolateral ligament reconstruction, patients with chondral damage Outerbridge grade >2, patients with meniscal tears undergoing subtotal meniscectomy or meniscal repair and patients with knee OA Kellgren–Lawrance (KL) grade >3. Results One hundred and fifty‐two patients were included in the study. Patients were divided into two groups according to surgical technique: Group A—ACLR with all‐inside technique, and Group B—ACLR with modified DB technique. There were no statistical differences between groups for age, side, gender or time since surgery. There were no statistically significant differences between groups for Lysholm scores (p = 0.43), IKDC (p = 0.88), ATT (p = 0.105) and KL grade (p = 0.93 before surgery, 0.99 at the fu). KL grade increased significantly since pre‐op. Conclusions Our data show significant improvements in all clinical outcome measures, along with excellent KT‐1000 arthrometer values and low clinical failure rates for both the SB all‐inside and modified DB techniques at a mean follow‐up of over 6 years. There were no significant differences in arthritic progression according to KL grade between groups. Level of Evidence Level III.

Background Dual mobility cup in total hip arthroplasties has gained popularity worldwide as it reduces instability providing greater range of motion. However, increased polyethylene wear remains debated. This in vitro study aimed to measure and qualitatively analyse the wear of ultra‐high molecular weight polyethylene in contemporary dual mobility cup compared to conventional single mobility acetabular component. Methods Hip simulator was used to compare ultra‐high molecular weight polyethylene wear in dual mobility and single mobility acetabular component The specimens were tested at an in vitro angle of 30° relative to the ISO standard fixated position. Flexion/extension, abduction/adduction, and internal/external rotation were simulated. Testing was stopped every 0.5 million cycles until 5.0 million cycles were reached and the liners were disassembled and weighted to assess mass loss. The test fluid was sent for scanning electron microscopy analysis and wear particles were characterized for mean equivalent circle diameter, form factor, maximum Feret diameter, minimum Feret diameter, area, perimeter and aspect ratio. Results Dual mobility hip reported a lower wear respect to single mobility (20.4 and 39.6 mg/Mcy, p < 0.01). Moreover, conventional acetabular component produced wear particles with higher equivalent circle diameter, area, perimeter, minimum and maximum Feret diameter, while aspect ratio and form factor resulted higher in dual mobility polyethylene wear. No cases of ultra‐high molecular weight polyethylene rupture have been reported. Conclusion Dual mobility cup produces less wear than conventional single mobility acetabular component ensuring lower risk of instability and greater range of motion. Further studies are needed to definitively clarify the issue of wear in the dual mobility prosthesis.

Purpose To compare the risk of a secondary bucket handle tear (BHT) of the medial and lateral menisci after an anterior cruciate ligament reconstruction (ACLR) with an unrecognized ramp lesion. The hypothesis was that an unrecognized ramp lesion would be associated with a secondary medial meniscus BHT more often than a lateral meniscus BHT. Methods A retrospective review of adults aged 18 or older who experienced a meniscal BHT after ACLR was conducted. An analysis of the clinical and radiological data from initial injury to revision surgery was completed. Two experts retrospectively documented the prevalence of ramp lesions present on preoperative magnetic resonance imaging (MRI) at the time of the index ACLR. The predictive value of a ramp lesion for BHT laterality was evaluated using logistic regression. Results Seventy‐six patients, 46 in the medial BHT group and 30 in the lateral BHT group, were included. A ramp lesion was present on the preoperative MRI in 33 patients in the medial BHT group compared to 13 in the lateral BHT group (p = 0.02, odds ratio: 3.2, 95% confidence interval: 1.2–8.0). In the logistic regression analysis, the only independent factor that predicted the occurrence of a medial BHT compared to a lateral BHT was the presence of a ramp tear on preoperative MRI before the index ACL surgery (logworth = 1.59; p = 0.03). Conclusion After a primary ACLR, an untreated ramp lesion was associated with a post‐operative medial BHT more often than a lateral BHT. Unrepaired ramp lesions may be a risk factor for subsequent medial meniscus BHT after primary ACLR. Level of Evidence Level IV.

Purpose To evaluate the incidence of anterior cruciate ligament (ACL) reconstructions in athletes who participated in the men's 2022 and women's 2023 Federation Internationale de Football Association (FIFA®) World Cups, comparing the incidence between genders, positions and the stages reached by the teams during the competition. Methods This is a media analysis study, and data were collected from official club and FIFA® websites: a list of athletes who played during the men's 2022 and women's 2023 FIFA® World Cup, a list of athletes who already did an ACL reconstruction (ACLR) and rehabilitation before the competition, and stages from each team during the competition. Results 12.5% of the athletes in the women's competition (92 athletes) and 7.7% in the men's competition (64 athletes) underwent ACLR surgery before. When comparing positions (goalkeeper, defence, midfield and forwards), there were no statistical differences between men (p = 0.97) and women (p = 0.26). According to the competition stage, the prevalence increased from 12.5% in the group stage to 17.4% in the finals (p = 0.05) for women and ranged from 6.8% to 7.9% (p = 0.87) among men. The number of ACL revision surgeries was 18 in women players (2.4% of total, 19.4% of those operated) and 5 in men players (0.6% of total, 7.5% of those operated). No statistical difference in revision rates between men and women (p = 0.16). Conclusion In the highest football level competition in the world (FIFA® World Cup), there was no statistical difference between the number of men and women called up and who participated after ACLR, rehabilitation and return to sport (12.5% vs. 7.7%; p > 0.05). Furthermore, the incidence of ACL‐operated players belonging to each team that played in the World Cup increased from the stage of groups to the final in the female category (p = 0.05), but remained stable in the male category (p = 0.87). Level of Evidence Not applicable.

Purpose This study aimed to analyse the 50 most cited publications on trochleoplasty (TP), examine their bibliographic parameters and evaluate the correlations between citation count, methodological quality and other factors. Methods In a comprehensive literature search on the Web of Science, the 50 most cited studies on TP were identified. These studies were then evaluated according to their bibliographic parameters, level of evidence (LOE), citation counts, the Modified Coleman Methodological Score (MCMS), the Methodological Index for Non‑Randomised Studies (MINORS) and the Radiologic Methodology and Quality Scale (MQCSRE). Results Of the top 50 list, 15 articles (30%) were published in the journal ‘Knee Surgery Sports Traumatology Arthroscopy’ (KSSTA). A total of 39 studies were published by institutes from Europe (78%), with France and Switzerland being represented 10 times each. Of eight different study types, case series (n = 25, 50%) and systematic reviews (n = 16, 32%) were the most prevalent. LOE included Level III (n = 1, 2%), Level IV (n = 41, 82%) and Level V studies (n = 8, 16%) studies. The total citation count amounted to 2481 citations, ranging from 10 to 187 (mean 49.6 ± 41.5) and showed a mean citation density of 5.1 ± 2.6. Quality scores were 60.8 ± 9.8 for MCMS (n = 26), 11.1 ± 2.9 for MINORS (n = 26) and 22.5 ± 2.1 for MQCSRE (n = 25), respectively. High citation counts did not statistically correlate with higher study quality scores (p > 0.05). Conclusion Overall, there is growing scientific interest in TP as a treatment option for patients suffering from patellofemoral instability despite the lack of articles with a high LOE and methodological quality. This review of the top 50 most cited studies provides orthopaedic surgeons with a resource to assess the most impactful academic contributions to TP. Level of Evidence Level IV.

Purpose To compare the radiological outcomes of medial closed wedge distal femoral osteotomy (MCWDFO) and lateral open wedge distal femoral osteotomy (LOWDFO), with a focus on evaluating leg length discrepancy (LLD). It was hypothesised that MCWDFO would result in a greater reduction in leg length compared to LOWDFO. Methods Patients who underwent MCWDFO or LOWDFO for valgus deformity at a single institution between 2014 and 2022 with a minimum follow‐up of 1 year were included. Radiological assessment included hip–knee–ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), length of the whole leg and femur and LLD. The difference between pre‐ and post‐operative values for each parameter is expressed as Δ. The radiological outcomes were statistically evaluated for each procedure. Results Fifty‐two patients (26 MCWDFO and 26 LOWDFO) were included. No significant differences were observed between the two groups with respect to demographic data and radiological parameters such as HKA, mLDFA and MPTA. Although Δ length of the femur decreased post‐MCWDFO (−2.7 ± 0.6 mm) and increased post‐LOWDFO (+2.7 ± 0.4 mm), the Δ length of the whole leg post‐MCWDFO decreased (−0.5 ± 3.8 mm) and increased post‐LOWDFO (+1.7 ± 2.6 mm) (p < 0.001). The straight‐lengthening effect on the length of whole leg was significantly greater in MCWDFO than in LOWDFO (+2.0 ± 4.1 mm vs. −1.1 ± 2.5 mm, p > 0.001). Conclusions The straight‐lengthening effect of alignment correction minimises changes in overall leg length, regardless of the specific DFO technique. Level of Evidence Level III, retrospective comparative study.